Nursing case study on gestational diabetes mellitus

Case Study

Nursing Care of the Patient With Endocrine Disease

Køren K. Gi,ttùngs

Unfolding Case Study #36 T,, Jenny

Jenrry is a56-year-old female who is scheduled for a routine primary care provider's (PCP) visit to follow-up on her hypertension. She reports no signi-ficant complaints other than her vision being blurry; she states, "I need to go to the eye doctor to have my eyes checked." At the conclusion of her visit, the PCP orders a basic meta- bolic panel (BMP) and complete blood count (CBC) to be drawn. Jenny receives a phone call 2 days later from her PCP's office to schedule an appointment for later that day. Jenny is told that her blood sugar is elevated. At her appointment, Jenny and the nurse begin by reviewing Jenny's risk factors for diabetes.

Exercise 6-lz Select øl.l tltøt øþþly Identify risk factors commonly associated with diabetes mellitus:

E Obesiry fl ege less than 45 years E Caucasianrace I Family history D History of gestational diabetes E History of delivering babies over 9 pounds

eResource 6-l: To review risk factors associated with diabetes, consult Epocrates Online: [Pathway: -+ hnpt//online.epocrates.com -> select the "diseases" tab -+ enter "Diabetes" into the search field -+ review content related to "risks"]

Jsnny reports that her mother and grandmother were diabetics. She is also over 45 years old and overweight at 5 feet 2 inches anld 2OO pounds. Jenny still finds it hard to believe that she could be diabetic since she is feeling okay; she asks the nurse to explain to her how diabetes occurs.

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216 CHAPTTR 6: ENDOCRINE DISEASE

Exercise 6-22 Multiple-cltoí.ce question The nurse educating Jenny on type 2 diabetes determines that she understands tþs information when she states:

A. "I am not producing any insulin because of a problem with my immune system."

B. "I will need to take insulin for the rest of my life.,' c. "I'm not making enough insulin or my body isn't as sensitive to it.,, D. "I won't need to make any dietary changes if I take my medicine."

Exercise 6-32 Møtcbing Match the type of diabetes in Column A with its typical characteristics in Column B Answers in Column A can be used more than once.

ColumnA Column B A. Type L diabetes Onset is usually under 30 years old B. Type 2 dial¡etes patient is often thin at time of diagnosis

Treated with diet, exercise, and oral agents

Patient is often obese at time of diagnosis

Antibodies are present in the body

Patients require insulin for life

G) ;ffi::i,"",'J ^ä¿'"äîîî#."å:*t'#i;:lË:iffi,îå:ä. _enter "Type 2 Diabetes" into the search field -+ in the "overview,'section, select "pathophysiology" and review content]

By the time it is Jenny's turn to see her PCP, she has a beginning understanding about diabetes. Her PCP sits with her and begins by reviewing hãr hboratory re- sults. Her fasting plasma glucose from her last visit was 236 mg/dL.The pCp lists some typical signs and symptoms of diabetes, and he asks Jenny if she is experi- encing any of them.

Exercise 6-4: Select ølt tbat øþpty Identify coÍunon clinical manifestations associated with diabetes mellitus

E rolyuria E Decreased appetite Q Decreased fluid intake E Vision changes fl natigue eResource 6-3: For more information regarrding clinical manifestations associated with diabetes mellitus, refer to the Merck Manual: fpathwayt www.merckmanuals.com + select "Merck Manual of Diagnosis and

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CFIAPTER 6: ENDOCRINE DISEASE Questions 217

o

Therapy" --> enter "Diabetes" into the search field + select "Diabetes Mellitus (DM)" -à select "Symptoms and Signs" and review content]

Jenny reports that her vision has been blurry, but she thought that she needed new glasses. She also recognizes that she has been drinking and urinating more than usual. Based on her symptoms and elevated fasting plasma glucose, the phy- sician suspects Jenny has type 2 diabetes.

eResource 6-4: To learn more about the diagnostic work-up for Jenny, refer to Medscape on your mobile device: [Pathway: Medscape *) enter "Type 2 Diat¡etes" into the search fleld + select "Type 2 Diabetes Mellitus" -+ select "'$7'orkup" and review content]

To further confirm the diagnosis, he orders a random fingerstick blood sugar and Hemoglobin A1C (HgbAlC).

Exercise 6-52 Sbort ønsu)er Briefly explain how a HgbAlC is used to evaluate blood glucose compared to a ran- dom blood glucose level.

o eResource 6-5zTo learn more about HgbAlC, refer to Medscape on yourmobile device: [Pathway: Medscape -+ enter "A].C" into the search field -+ select "Hemoglobin A1C testing"and review content]

Jenny's blood results are ready within a short period of time. Her fingerstick blood sugar is 286 and her HgbAlC is 9%. Her physician orders metformin 500 mg orally twice a day, andJenny is scheduled to meet with a diabetes educator in2 days.

Exercise 6-6: Fill-in Identify three ways in which metformin acts to maintain normal blood glucose levels:

1

2

3

o eResource 6-6:To review patient teaching regarding metformin withJenny, refer to Epocrates on your mobile device: [Pathway: Epocrates -> enter "metformin" into the search field + select "metformin" -) scroll down to review "common reactions" and other relevant content]

Jenny meets with the diabetes educator as scheduled. During her appointment, they discuss many topics including nutrition and exercise. The educator begins by talking about meal planning and caloric needs.

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218 CHAPTER 6: ENDOCRINE DISEASE guestions

rxefcrse o- / 2 .Íttt-Nt . For obese patients who are diabetic, the key to treatment is:

Exercise 6-8: Fùll-in Identify the food groups that are part of the Exchange List system and give one ex- ample of a specific food within each group:

Exercise 6-9: True orfølse Identify whether the following statements about nutrition in the diabetic patient are true or false:

1. Soluble fiber lowers blood glucose levels by slowing the rate of glucose absorption from these foods.

2. Alcohol used in combination with chlorpropamide (Diabinese) may cause facial flushing, warmth,.rrauseal and vomiting.

3. Nutritive sweeteners have no effect on blood glucose levels.

Exercise 6-l0t Multìple-cltoíce question The nurse educating Jenny on exercise determines that she needs further instruction when she states:

A. "Exercise will lower my blood glucose level.,, B. "I should try to exercise at the same time each day.,, C. "Walking is generally a safe form of exercise.,' D. "I should exercise more when my glucose levels are more than

25O mgldL;'

o eResource 6-72 To learn more about nutritional management of patientswith diabetes, refer to Medscape on your mobile device: [pathway: Medscape -+ enter "nutrition" into the search field -+ select "Nutritional Management of Patients with Diabetes" and review content]

Jenny is given a blood glucose monitor with instructions for self-monitoring of her glucose levels. Once Jenny's blood glucose level is stabilized, she is instructed to test at least fwo to three times per week.

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CHAPTER 6: ENDOCRINE DISEASE Questions 219

Exercise 6-ll: Select øll tltøt øpply Identify other ci¡cumstances in which more frequent testing is recommended:

D Missing a mealtime Ü Symptoms of hypoglycemia I Changes in medications E During periods of increased stress E Times of illness

The diabetes educator explains to Jenny how metformin works to control her blood glucose level. Jenny expresses concern that she may have to use insulin if the metformin is ineffective, but the nurse explains that there are many other oral agents availat:le that can be tried before moving to insulin.

Exercise 6-l2t Mø.tcbing Match the medication in Column A with its drug classification and action in Column B.

ColumnA A. chlorpropamide

(Diabinese)

B. glipizide (Glucotrol)

C. metformin (Glucophage)

D. acarbose (Precose)

E. nateglinide (Starlix)

Column B Alpha-glucosidase inhibitor; delays intestinal absorption of complex carbs First-generation sulfonylurea; stimulates beta cells of the pancreas to secrete insulin

Nonsulfonylurea insulin secretagogue; stimulates th.e pancreas to secrete insulin Second-generation sulfonylurea; stimulates beta cells of the pancreas to secrete insulin Biguanide; inhibits production of glucose by the liver

o eResource 6-8: To learn more about these medications, consultMedscape on your mobile device: [Pathway: Medscape -) enter "Type Z Diabetes" -+ select "Medication" and review content]

As Jenny's appointment draws to an end, the diabetes educator teaches her about hypoglycemia and long-term complications.

Exercise 6-15: Multiple-cltoice question The nurse educating Jenny on hypoglycemia determines that she understands the in- formation when she states:

A. "I won't get hypoglycemic when I am only taking metformin.,' B. "If I feel my blood sugar dropping, I will eat some chocolate candy)' C. "My family should be educated on how to help me if I become hypogþemic." D. "Hypoglycemia most often occurs t hour after meals."

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220 CÉ{APTER 6: ENDOCRINE DISEASE Qøes¿loøs

Exercise' 6-14: Fnll-nn Identify the macrovascular and microvascular complications that can occur witlì diabetes:

Macrovascular Microvascular L

eResoufce 6-9zTo learn more about microvascular and macrovascular complications, refer to Medscape on your mobile device: [Pathway: Medscape -+ enter "Type 2 Diabetes" -> select "Treatment and Management" -) select'Approach and Considerations" and scroll down to review contentl

Exercise 6-15: Select øll tÍtøt øpply Identifiz foot care techniques recommended for diabetic patients

B Assess feet daily E Lotion the feet, especially between the toes fl Use hot water for soaking the feet D trim toenails straight across E Never walk barefoot

o eResource 6-LO: To supplement patient teaching regarding diabetes,refer to: I MedlinePlus's interactive tutorial, Dia.betes-Introduction:

http://goo.gl/nJn7B I National Institutes of Health's (NIH's) pamphlet, Your Guid.e to

Diabetes: Type 1 and Type 2:http://goo.g/bgBNl

eResource 6-L1: To learn about the American College of Physicians recommended vaccinations forJenny to help keep her healthy, download the ACP Immunization Advisor (ACP-IA) "app" onto your mobile device (http://goo.gllNzQlB). [Pathway on your mobile device: ACP-IA -> select "frrud" -+ enter "age" aîd "Condition" (Note: There are no special considerations for Jenny) -+ select "Show Vaccines"]

Unfolding Case Study #37'% Lorrie

Lorrie is a 60-year-old female who was recently diagnosed with hypothyroidism. Her granddaughter, Alissa, who is in college studying to be a registered nurse, is very interested in learning more about hypothyroidism so that she can help to educate her grandmother about her disease process. Alissa begins by reviewing basic anatomy and physiology of the thyroid gland.

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CI-L{PTER 6: ENDOCRINE DISEASE Qøestlo'?s 221

Exercise 6-16z Select øll tltøt aþþly

ldentrfy the hormones released by the thyroid gland:

B ftryroxitte (T4) Q Thyroid-stimulating hormone (TSH)

E Triiodothyronine (T3) E calcitonin E ,tntidiuretic hormone (ADH)

Exercise 6-17: Fíl'l-i.n

Essential for the synthesis of thyroid hormones,

through diet.

Exercise 6-7.82 Sbort a'nsu)er

Briefly explain how the release of thyroid hormone is regulated in the body.

is obtained

o eResource 6-L2:To learn more, Alissa refers to Medscape on hermobile device: [Pathway: Medscape -+ entef "hypothyroidism" -+ select "Ovefview" -) review content listed under "Background," "Epidemiology," and " PathophysiologY"J

Alissa is aware that many endocrine disorders have general signs and symptoms,

which may be initially ignored or thought of as being a part of the normal aging process. Áirr" asks her grandmother what types of signs and symptoms she was experiencing.

Exercise 6-t9z P¡l'Lín Identify three common signs and symptoms that may indicate an endocrine disorder:

1.

)

3.

eResource 6-t3:To learn more about coÍunon signs and symptoms associated with an endocrine disordeq refer to the Merck Manual: I Hypothyroidism: [Pathway: www.mefckmanuals.com -) select "Merck

Manual of Diagnosis andTherapy" -+ entef "hypothyroidism" into the

search field + select "hypothyroidism" -+ select "symptoms and Signs" and review content]

I Endocrine Disorders: [Pathway: www.merckmanuals'com -t select "Merck Manual of Diagnosis and Therapy" -) enter "Endocrine Disorders" into the search field -+ select "Endocrine Disorders" and

review content]

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222 CIIAPTER 6: ENDOCRINE DISEASE

Lorrie tells her granddaughter that she had been feeling very tired and hadenergy for cleaning the house or family activities. Because she didn't initiallyanything was really wrong, Lorrie did not seek medical attention, but waitedher regularþ scheduled púmary carcprovider's (PCp) appointment 3 monthsto mention her fatigue. Her pCp ordered some laboratory tests to be done onday and scheduled her for a follow_up appointment in 1 week.

Exercise 6-2O: Select ølt tbøt øppty Identify clinical manifestations associated with hypothyroidism:

fl weight loss E Fatigue E lrritability D Hair loss D Increased pulse fl Feeling cold in awarmenvironment

oË,i::ä::'i"',ÍJ;,';î:å,ä?T3:ï:"i:,;å:1f, ,ffi,î1ïï:',1îî::"n field -+ select "crinicar presentation" and r*i.* åontentl

Exercise 6-2Iz LIøtcttí.ng Match the laboratory test in column A with its description and normal value in Column B.

ColumnA A. TSH

B. T3

C. T4

D. Free T4

Column B _7Û%o is protein-bound; normal is 5 to L.). mcg/dL

-

Direct measurement of unbound thyroxine; normal is 0.8 ro 2.7 ng/dL

-

Best screening test for thyroid function; normal is 0.4 to 4.2 nIU/L

_ More accurate indicator of hyperthyroidism; normal is 70 to 204 ng/dL

o;::,:ö::,9"ïJ;,Y:ååË3:ï:i:ffi :,";,;ffi,T*,,in,o,he search field -+ select "work-up" -> select

,,íiboritory studies,,and review contentJ

At her follow-up appointment, Lorrie received her diagnosis of hypothyroidismand was started on levothyroxine (synthroid) 0.075 *g"or"tiy daily.Later,Alissa reviews the medication with her grandmother so that sãe clearly understands theneed to continue taking it as direited.

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CHAPTER 6: ENDOCRINE DISEASE Questions 223

Exercise 6-22: True orla.lse Identify whether the following statements about thyroid hormone replacement ther- apy are true or false:

1. TSH levels are used for monitoring the effectiveness of thyroid hormone replacement and in making dosage adjustments of the medications.

2. Signs of overdose are manifested as hyperthyroidism (tachycar- dia, weight loss, nervousness, and/or chest pain).

3. Thyroid hormone replacement is only needed until symptoms subside; the medication can then be discontinued.

eResource 6-16z To learn more about this medication, Alissa consults Epocrates on her mobile dêvice: [Pathway: Epocrates -+ enter "synthroid" into the search field + review contentl

@

Since Lorrie has only recently been diagnosed with hypothyroidism and started on levothyroxine (Synthroid), she continues to have some- clinical manifestations that she did not previously know were related to the hypothyroidism. Lorrie continues to tire easily, feel cold despite'warmer environmental temperatures, and struggle with constipation. Alissa has found some nursing interventions through her study of hypothyroidism tl:rat may be useful to her grandmother.

Exercise 6-23: Multiple-cltoi.ce questíon V/hen educating her grandmother on controlling her fatigue, Alissa determines that she understands the information when she states:

A, "I should push to get all of my housework done in one block of time." B. "f don't want to ask for help; I need to keep pushing myself." C. "I need to get used to feeling tired since I will feel like this the rest of my life." D. "I need to space my activities so I can rest in befween."

Exercise 6-242 Multþle-cboice qaesti.on \Øhen educating Lorrie on how to maintain a normal body temperatt)re, her grand- daughter determines that she needs further instruction when she states:

A. "I can just layer my clothing to provide more warmth." B. "I can use heating pads or an electric blanket when I go to bed." C. "I should stay aw^y from cold, ûafty areas." D. "I won't feel cold all the time once my medicine starts working."

Exercise 6-25: Select øll tbøt øþþly Identify interventions designed to improve constipation:

D use laxatives regulady D Increase fluid intake if no restrictions E Increase activity as tolerated E Use enemas on a biweekly schedule fl Increase fiber content in diet

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224 C}IAPTEP. 6: ENDOCRINE DISEASE

o Ilypothyroid.ism: lvba.t Euery parient Needs toeResource 6-172 Fot more patient education informafion, referKnout: Alissa has compreted her study of hypothyroidism and educated heron her disease process, but she decides to review a rittle information roidism since she knows that this can occur as a result of ingestion thyroid hormone.

Exercise 6-26: Select øil tba.t øþþty Identift clinical manifestations associated with hyperthyroidism:

on of

fl Nervousness fl Heat intolerance E Progressive weight gain Ü Poor appetite and decreased intake D Tachycardia

Exercise 6-27. F¿lt-irt Identify three atypical signs and symproms of hyperthyroidism rhat the elderþ may present:

Gl eResource 6-rg: Arissa uses Medscape on her mobile device tov supplement her_understanding of hyperthyroidism: [pathway: Medscape-) enter "hyperthyroidism" into the sãarch field -+ rãview contentl

Exercise 6-28: True orføtse Identifir whether the following statements about laboratory results used to diagnose hyperthyroidism are true or false:

1. TSH levels are decreased with untreated hyperthyroidism. 2. Free T4 levels are decreased with untreated hyperthyroidism.

1.

)

:).

Unfolding Case Study #jg % finda Linda is a 59-year-old femare with a medical history of hypertension, asthm a, andchronic bronchitis. sle ha_s a pasthistory of smoking orré ,o one and aharfpacksof cigarettes per day for 35 years. Linda quit smokin! when her asthma worsened;she has been smoke-free for 3 years now. As part of her treatment regimen, Lindahas been takingprednisone 2o mg oru:|ry dairy forthe past ii ,rrorrtrrr. at her mostrecent primary care provider's (PCP) appointment, ;"iida expresses concern at the

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